A parent rushes their pre-school age child to the emergency department with an asthma exacerbation.
Which additional finding should alert the nurse that the child is in acute respiratory distress?
Flaring of the nares.
Bilateral bronchial breath sounds.
Diaphragmatic respirations.
Resting respiratory rate of 35 breaths/minute.
Resting respiratory rate of 35 breaths/minute.
The Correct Answer is A
Flaring of the nares is a sign of respiratory distress in children. It indicates that the child is working harder to breathe.
Choice B rationale
Bilateral bronchial breath sounds are normal and do not indicate acute respiratory distress.
Choice C rationale
Diaphragmatic respirations are normal in children and do not indicate acute respiratory distress.
Choice D rationale
A resting respiratory rate of 35 breaths/minute is within the normal range for a preschoolaged child and does not indicate acute respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Immediately after delivery, the breasts of a new mother are not likely to remain the same as before delivery. Hormonal changes during pregnancy prepare the breasts for lactation, and these changes do not typically revert immediately after delivery.
Choice B rationale
On the first postpartum day, the breasts of a new mother are most likely to be filling and secreting colostrum. Colostrum is the first form of milk produced by the mammary glands, and it usually starts to be produced during pregnancy and continues during the early days of breastfeeding.
Choice C rationale
An immediate let-down response is not typically observed on the first postpartum day. The letdown reflex, which releases milk from the breast, usually becomes more pronounced after the first few days of breastfeeding.
Choice D rationale
While the breasts may become larger due to milk production, they are not typically very tender to touch on the first postpartum day. Tenderness may occur later, especially if complications like engorgement or mastitis develop.
Correct Answer is C
Explanation
Choice A rationale
Keeping plastic bags of ice in the freezer is not specifically indicative of successful management of hemophilia. While ice can be used to manage acute joint bleeds, it does not reflect the overall management of the condition.
Choice B rationale
Wearing extra pads when playing football could indicate an awareness of the risk of injury, but it does not necessarily reflect successful management of hemophilia. In fact, contact sports like football are generally not recommended for individuals with hemophilia due to the risk of bleeding.
Choice C rationale
Serving as a counselor at a camp for hemophiliacs could indicate successful management of hemophilia. It suggests that the individual has not only learned to manage their own condition, but is also able to provide guidance and support to others with the same condition.
Choice D rationale
Chewing food slowly to prevent injury to the gums is a precautionary measure, but it does not necessarily indicate successful management of hemophilia.
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